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~ APPLAT ION FOR ENCROACHMAT PERMIT to 61 - <br />PLEASE <br />PLEASE PRINT: <br />Date 4 2 0 �f-s�- <br />To: San Joaquin County Highway Department. <br />c <br />-e— SMA <br />(Applicant Name) <br />So /4 r; ('e4 M C <br />(Mailing Address) <br />( 'ity, State Zip Code) <br />26 3 /- 3 -7S <br />(A Code - Telephone Number) <br />OFFICE USE ONLY <br />JOB # REFfl <br />APN - CRV# <br />EXP. DATEi99s- <br />VALIDiW,4,DRIVEWAYS: <br />STREET��.uGyaN sT. <br />AREA QUAD y✓ 5, <br />TYPE <br />FORMS s s/w w , ze - 2 2 <br />NOTE <br />('--0 n 772. W11 -L 7-t)LAL-- n -I 57PI , <br />Sketch (Detailed plana may be , submitted) <br />- T. <br />.� <br />• q . C. <br />a. <br />' ami \F,&A-S 44 I lVGTo nJ <br />�T <br />-C3v- <br />1= o <br />�? Q C�j Y <br />V <br />The undersigned hereby applies for permission to excavate, construct and / or otherwise encroach on County <br />I-N.ighway Right -of -Way on the side of -approximately <br />feet / mile k),.& of o c` , �a.� , by performing the <br />following work: (description of work j: <br />Work will commence on or about ,�/%g y /, / 35s� for approximately / F d days. <br />I the undersigned certify that I am the owner of the respective property, or am qualified to represent the owner and <br />agree to do the work described above in accordance with the rules, regulations of San Joaquin County and subject <br />to ins pe and appy val. <br />SIGNATURE OF APPL ANT -TITLE DA <br />